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Attention Deficit Hyperactivity Disorder ADHD Solutions


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Title: Attention Deficit Hyperactivity Disorder ADHD Solutions

  • Attention Deficit Hyperactivity Disorder

Personal Insight
  • A teachers insight.
  • A to Z Teacher Stuff
  • At home - ADD
  • My sons perspective
  • Personal experience

Take Home Messages
  • AD/HD is not a disease nor is it a joke do not
    blame the person nor trivialize the condition.
  • Students with moderate to severe AD/HD are highly
    at risk for behavioral, emotional and academic
  • Those with AD/HD can and do succeed with proper
    diagnosis, intervention and support.

  • Overview and Definitions
  • Etiology Key Issues
  • Scope, Prevalence and Comorbidity
  • Successful Strategies (over 25!)
  • Summary

First, An Overview
  • Lets get a critical understanding of the
    condition with its associated features and a
    discussion of key diagnostic issues.

Clinical Definition (1 of 2)
  • AD/HD is a persistent disabling pattern of
    behavior. It occurs more frequently and with
    greater consequences than is typically observed
    in others at a comparable level of development.

Clinical Definition (1 of 2)
  • AD/HD is a condition characterized by
  • Poor short term memory
  • Hyperactivity
  • Impulsivity
  • Poor time management

Clinical Definition Key
  • All AD/HD behaviors can be considered normal for
    some people, at some age for a certain time.
    With AD/HD, these behaviors are the rule and not
    the exception and they are age inappropriate.
  • Source DSM-IV-TR, 2000

Clinical Qualifiers
  • Onset before age 7 yrs.
  • Diagnosis often delayed until problems in school
  • In two of three settings - home, school, office
  • Rule out other potentially look-alike
    psychiatric disorders such an oppositional
    disorder, sensory integration disorder, central
    auditory processing disorder, learning delays,
    schizophrenia, stress disorders, psychosis or
  • Source DSM-IV-TR, 2000

Diagnosis (1 of 2)
  • The AD/HD diagnosis carries with itsignificant
    implications for families, educators and of
    course, the child.Only a licensed professional,
    such as a pediatrician, psychologist,
    neurologist, psychiatrist or clinical social
    worker, can make the diagnosis that a child,
    teen, or adult has AD/HD.

Diagnosis (2 of 2)
  • Health care professionals use the Diagnostic
    and Statistical Manual of Mental Disorders, 4th
    Edition, Text Revised (DSM-IV-TR) as a guide
    (APA, 2000).

AD/HD Behaviors/Symptoms
  • Poor short-term memory
  • Weak at following directions
  • Asking another what was just said
  • Looking at others to figure out what was said
  • Late for time commitments
  • Desk is a mess--poorly organized
  • Forgetting about promises made
  • Knowing what and how but not knowing when and
    where to do it--its appropriateness

More AD/HD Behaviors/Symptoms
  • Spacey, poor concentration
  • Weak time orientation
  • Cannot plan ahead
  • Poor at reflecting on past
  • Makes the same mistakes over and over
  • Poor time management

Other Common Behaviors/Symptoms
  • Unable to curb their immediate reactions
  • They act before thinking
  • They hit or grab first, then realize it later
  • Blurt out inappropriate comments
  • Nearly impossible for them to wait for
    things--little or no patience

Hyperactive-only Behaviors
  • Cant stay in their seats
  • Always want to be in motion
  • They can't sit still, dash around
  • They squirm, wiggle and touch everything
  • Less focus they try to do several things at

More AD/HD Milestones (3 of 5)
  • 1980
  • APA (American Psychiatric Association)
    identified the condition as a disorder in the DSM
    III. Two behavior patterns were listed
  • Attention Deficit Disorder (ADD) and Attention
    Deficit Disorder with hyperactivity AD/HD
  • 1983
  • Amphetamines prescribed to treat AD/HD including
    Ritalin and AD/HD Adderall usingNational
    Rehabilitation Act, Section 504

Most Recent AD/HD Milestones(5 of 5)
  • 1994
  • DSM IV) Three Subtypes Defined
  • 1997
  • Based on office visits, those diagnosed with
    AD/HD reached 3.3 million children nearly over 5
    percent of all children (U.S. figures).
  • 2003
  • AD/HD becomes the number one diagnosed
    school age disorder in America

Brain Differences in AD/HD Subjects
  • Neurotransmitter imbalances
  • Lower cerebral blood flow Lou, et al., (2004)
  • Anatomical differences between healthybrains
    and those with AD/HD
  • Castellanos, et al. (2002), Castellanos and

Brain Differences in AD/HD Subjects
  •  Magnetic Imaging Resonance (MRI)
  • found a range of abnormalities in
  • brain development associated with AD/HD
  • Brains are 3-4 smaller in more frontal lobes,
    temporal gray matter, posterior inferior vermis,
    caudate nucleus and cerebellum.
  • Castellanos F. Acosta M. (2002)

AD/HD and Other Disorders
  • 25 of children diagnosed with AD/HD also
    qualify for a diagnosis of oppositional defiant
    or conduct disorder (CD).
  • Nearly 20 of children with AD/HD also have a
    depressive disorder.
  • More than 25 of children with AD/HD qualify for
    a diagnosis of anxiety disorder.
  • Almost 33 of children with AD/HD also have more
    than one comorbid condition.

Comorbidity (appearing together)
  • More often than not, AD/HD presents itself with
  • other cognitive and behavioral issues including
  • Oppositional defiant disorder
  • Conduct disorder
  • Dyslexia
  • Anxiety and mood disorders
  • Depression
  • Learning disorders
  • Tourettes disorder
  • Obsessive-compulsive disorder (OCD)
  • Attention Deficit Hyperactivity Disorder A
    Decade of the Brain Report.96-3572, (1996).
    Bethesda, MD National Institute of Mental

Comorbidity of AD/HD Summary
  • Prevalence rates of comorbid AD/HD are high.
    Estimates of various comorbid conditions in
    children with AD/HD range from 12 (learning
    disorders) to 35 (behavioral disorders) to as
    much as 92 percent in all. (Osman, 2000).
  • Current literature indicates that approximately
    4060 percent of children with ADHD have at least
    one coexisting disability. (Jensen, et al.,

Will Children with AD/HD Outgrow It?
  • 50-65 of children with AD/HD present symptoms
    into adulthood (Korn Weiss, 2003)
  • 30-40 of grownup AD/HD children do well.
  • 10-20 have significant impairment and
  • 80-90 do not need medication as adults.
  • Barkley, (2002)

AD/HD Symptoms into AdulthoodAdults May
  • Experience difficulty working, finishing
    assignments or meeting deadlines because they
    cannot concentrate or are easily distracted.
  • Interrupt people who are speaking by cutting
    them off in the middle of a conversation.
  • Be restless or impatient at meetings.
  • Arrive late to work or meetings because of poor
    organizational skills or forgetfulness.
    (Biederman et al., 2003)

Gender and AD/HD Issues
  • Elementary age males were more than two times as
    likely as females to have been diagnosed with
    AD/HD in 2003 (9 percent versus 4 percent
  • By age 14, (late adolescence), girls and women
    are identified more than boys.
  • Many critics have suggested that elementary
    school seems better designed for girls, not boys.
  • Biederman, et al. (2002)

Differences by Ethnic Origin
  • Proportionally, more Anglos are diagnosed with
    AD/HD than nonwhites.
  • In 2003, 8 of non-Hispanic white children and 6
    of non-Hispanic black children had been diagnosed
    with AD/HD compared with only 4 of Hispanic
  • These disparities suggest the possibility that
    income and cultural differences may affect both
    perception and analysis of the behaviors. Pastor
    and Reuben, (2005)

Risk Factors of AD/HD
  • Academic underachievement
  • Legal problems
  • Substance abuse
  • Social difficulties
  • Risky behaviors

How Risky is Untreated AD/HD?
  • 35 of students dropout with AD/HD
  • 5-10 will complete college
  • 40-50 will engage in antisocial activities
  • 50-70 have few or no friends
  • 70-80 will under-perform at work
  • More likely to experience teen pregnancy and
    sexually transmitted diseases
  • Greater risk for excessive speeding and accidents
  • Higher risk for depression and personality
  • Source Barkley, (2002)

Diagnosis and Discussion
  • What are potential explanations for the rapid
    increase in diagnosis of AD/HD?
  • Awareness and marketing of pharmaceuticals
  • Less of stigma to taking meds
  • Kids grow up in a faster 24/7 worldit may
    harder to focus
  • Better diagnosis and treatment by medical
  • More children in childcare, for more years
  • Change in early childhood activities
    (moreelectronic games played that reward

Validity Issues Is AD/HD Real?
  • AD/HD is a psychiatric diagnosis, nota
    disability category recognized by the Individuals
    with Disabilities Education Act (IDEA) (Salend
    Rohena, 2003).
  • At present, no laboratory test exists to
    determine if a child has this condition. You
    can't diagnose AD/HD with a urinalysis, blood
    test, EEG, PET, fMRI or SPECT scan, though these
    can help.
  • Should students with AD/HD adapt to theadult
    world or the reverse?

What About Simply A.D.D.?
  • Students with Attention Deficit Disorder onlydo
    not have the hypersymptoms of movement. As a
    result, they tend to be still impulsive, but they
    stay in their chairs. Theyre impulsive
    cognitively but unfocused and stationary.

Etiology Possibilities
  • Major changes in the last two generations may be
    a source for possible explanations for the AD/HD
  • 1. Childrearing Tactics
  • 2. Nutrition Changes
  • 3. Stress/anxiety
  • 4. Screen/Computer time

Childrearing Changes
  • Close, nurturing parenting isneeded from ages
    0-5 and the brain has higher vulnerability to
    environmental influences. Rice and Barone
  • In 1960, an estimated 10 of all children were
    in childcare. Today, over 60 of all kids will
    spend time in childcare.
  • NICAD (2003)
  • More children watch more fast-paced TV with
    stressful, violent images. Less chaotic, less
    stressful upbringing may help the brain develop
    differently. (Christakis et al. 2004)

Nutrition Links (1 of 2)
  • Studies link excess sugar and poor diets with
    behavioral problems in children. (Jacobson,
    1996 and Werbach, 1998)
  • Among infants 24 months or less, 1 in 9 have
    French fries daily, 1 in 4 have hot dogs daily.
    (Fox et al., 2004)
  • Children eat far more processed foods
    withpreservatives, additivesand trans fats than
    atany time in history.

Nutrition Links (2 of 2)
  • AD/HD meds such as Methylphenidate (Ritalin)
    increase dopamine or Straterra increase our
    brains norepinephrine. Diet alone may support
    this process.
  • Specific dietary supplements may include the
    amino acid tyrosine, essential fatty acids and
    phospholipids.Tyrosine is converted into
    dopamine in the brain.(Harding et al., 2003).

InterventionsPractical Strategies for Parents
and Teachers
  • Review of both the mainstream and alternative
    treatments. Explore both short-term and lifelong
    strategies for successful healthy living.

Your Choices
  • 1. Changes within the student (meds,
    skill-building, nutrition, self-awareness, etc.)
  • 2. Changes in the environment (more mobility,
    change in teachers, cooler room, etc.)
  • 3. Changes in the teachers behavior (more
    awareness, accommodations, skill-building, etc.)
  • 4. Changes in the overall school culture
    (awareness, greater appreciation for
    differences, etc.)
  • 5. Influence parenting (less nagging, greater
    support, more consistency, etc.) NOTE Where do
    you have the most control?

When You Treat AD/HDWhats the Goal?
  • To change behavior, ofcoursebut how?All
    AD/HD-related behavior change focuses on
    strengthening the capacity of the frontal
    lobes. This can be done chemically or

Mainstream Treatments
  • When AD/HD is moderate to severe, the typical,
    mainstream, multimodal treatment plan is likely
    to include medication.
  • The typical multi-modal treatment approach
    consists of four core interventions
  • Patient, parent, and teacher education about the
  • Medication (usually from the class of drugs
    called stimulants) or nutritional support
  • Behavioral therapy
  • Environmental supports, including an appropriate
    classroom accommodations.

Actual Mainstream Treatments Used
  • Medications
  • Medications
  • Medications
  • Some behavioral therapy is used, but many medical
    staff are untrained in a wide range of behavioral
    strategies (and follow through is problematic)

The Use of Stimulants
  • Effectiveness ranges from 75-95. Why not 100
  • wrong medication
  • dosage issues
  • compliance issues
  • improper diagnosis
  • comorbidity
  • contraindications

Trial and Error
  • Because no single AD/HD drug always works for
    every child, doctors depend on parents' and
    teachers' input in prescribing medicine for
  • Often more than one drug must be tried before a
    child's behavior improves, and side effects
    always need to be evaluated.
  • Medicines are also available in longer acting
    forms, which may allow the child to go through a
    school day without a lunch time dose of medicine
    from the school nurse.

Before and After TreatmentA Tale of Two Brains
  • Using SPECT scans, we are seeing the underside
    of two brains (the top two are the same brain and
    the bottom two are the same brain). The scan on
    the left was taken before an intervention and the
    one on the bottom was taken a year later after
    meds and behavioral therapy. The dark holes are
    areas of metabolic underactivity, not actual
    missing chunks of matter.
  • images courtesy of Daniel Amen

Most-Prescribed Stimulants
  • Ritalin -one dose lasts up to 4 hours
  • Metadate Ritalin once a day lasts up to 12
  • Focalin Ritalin derivative lasts up to 4 hours
  • Attenade-Ritalin derivative-lasts 6 hours
  • Straterra lasts for up to 12 hours
  • Concerta- once a day lasts up to 12 hours
  • Dexedrine-last 4 hours-spansule lasts 10 hours
  • Adderall- once or twice a day, lasts longer
    than Ritalin

Most-Prescribed Stimulants
  • NOTE Many new AD/HD products are repackaged
    formulasoriginally used for another purpose many
    years ago.Morbidity Issues
  • Safe track record for prescription oral
  • Methylphenidate is non-lethal when taken orally,
  • When taken intravenously, effects are similar to
  • Methamphetamine is a class I narcotic (as is
    morphine, opium and cocaine)

Stimulants and Substance Abuse
  • A meta-analytic review of the literature shows
    there was an almost twofold decrease in the
    likelihood of substance abuse disorders for
    youths treated previously with stimulant
    medication. (Wilens, et al. 2003)

Potential Stimulant Side Effect Risks (1 of 2)
  • Headache/jittery feeling
  • Gastrointestinal upset
  • Loss of appetite (anorexia)
  • Emotional oversensitivity
  • Irritability or tics
  • Increased blood pressure
  • Blood glucose changes

Potential Stimulant Side Effect Risks (part 2 of
2) Lifestyle Effects
  • Sleep difficulty and irritability
  • Depression and anxiety
  • Headaches
  • Slowed growth rate (growth may be recovered
    after medication stopped)
  • Gogtay et al. (2002)

Treatment Protocol
  • Some children with AD/HD qualify for services
    within the public schools
  • An Individualized Educational Program (IEP) may
    be developed for AD/HD
  • Special education services under the Individuals
    with Disabilities Education Act (IDEA, 1997)
  • National Rehabilitation Act, Section 504

Behavioral Modification Programs
  • Parental and teacher strategies typically using
    positive and negative reinforcements for specific
  • Token reinforcement programs
  • Home-based contingencies
  • Use of rewards, privileges or restrictions

Six Alternative Treatments
  • When AD/HD is mild to moderate, these
    interventions may be highly effective without
    the use of medications.
  • Nutritional Support
  • Lifestyle
  • Skill-Building
  • Neurofeedback
  • Environmental Changes
  • Student Asset-Building

Nutrition (part 1 of 2)
  • Provide a balanced breakfast with extra protein
  • Reduce/remove additives and dyes (these are
    common causes of the some AD/HD symptoms)Boris
    and Mandel (1994)
  • Reduce sugars, cut high-fructose corn syrup--its
    in 1000s of foods
  • Remove allergens from the diet

Dopamine is a Brain Upper and You Can Influence
  • Dopamine is metabolized in the brain from the
    amino acid tryptophan (found in proteins).
  • Classroom activators are winning, smiles,
    celebration, anticipation of rewards and
    repetitive gross motor activities.
  • Energizers also releaseadrenaline, too

  • Some product types may lend nutritional support
  • Attend - a natural product which combines amino
    acids, andhormone precursors to
  • Tyrosine - Amino acid supplement which may
    increase alertness and focus
  • Other natural products such as cocoa, tea and
    lean proteins.
  • NOTE This is not an endorsement of these

Lifestyle Changes (1 of 2)
  • Limit television and video games
  • Avoid labeling and put-downs
  • Encourage student to join positive affinity
    groups, clubs, teams
  • Provide a variety of stimulating learning
  • Reduce unnecessary academic stress

AccommodationsSpecific Strategies (1 of 10)
  • Dealing with short-term memory issues
  • Some instructions may need to be repeated
  • Break tasks into small units
  • Set make able deadlines for each task
  • Make lists of what you need to do
  • Pre-plan the best order for doing each task
  • Make a schedule for doing tasks

Accommodations Specific Strategies (2 of 10)
  • Establish your routines and stick to them.
  • Create high predictability through daily and
    weekly events that always happen on cue.
  • Start the same way, transition the same way and
    end the same way.
  • Add variation only when its acknowledged as a

AccommodationsSpecific Strategies (3 of 10)
For organizational challenges
  • Use a calendar/planner to keep on track
  • Write down things you need to remember
  • Write different kinds of information in different
  • Keep the book with you all of the time
  • Post notes to yourself - tape notes on mirrors,
    refrigerator, locker
  • Store similar things together/Create a routine,
    use small travel clocks

AccommodationsSpecific Strategies (4 of 10)
  • Manage the movement!
  • Include far more movement--let them stand
    instead of sit, walk instead of stand and perch
    instead of sit.
  • Limit open space time, except as group activities
    -otherwise it may encourage opportunities for
    inappropriate impulsivity and movement.
  • Set up a signal system so you can talk to the
    student while class is going on. There might be a
    signal that tell the student its time for him to
    go to the back of the room or take a walk.

AccommodationsSpecific Strategies (5 of 10)
  • Sharpen your communication
  • Externalize important information, making it easy
    for access and obvious (notes, signs, partners
  • Provide clear instructions keep oral
    instructions brief and repeat them as necessary
    provide written instructions (and review them
    orally) for multi-step processes break up tasks
    and homework into small steps.

AccommodationsSpecific Strategies (6 of 10)
  • Manage the information flow. Show them how to
    cover up their work when they have a list.
  • Provide helpful self-check criteria -- direct
    them to check their work before turning it in.
  • Establish and use daily checklists for
    homework, due dates and even textbooks/supplies
  • Write out things, say them twice and let students
    write out the key words in the air for better
    attention and recall

AccommodationsSpecific Strategies (7 of 10)
  • Increase feedback
  • Focus on student successes -- build on positives,
    praise the success in every little thing.
  • Acknowledge part-way progress
  • Externalize sources of motivation use class
    charts or a point system so anystudent earns
    points towards classroom privileges
  • Use teams to improve peer feedback.

AccommodationsSpecific Strategies (8 of 10)
  • Help them manage time.
  • Break up the future into small, external chunks
    (calendar, post-its, etc.)
  • Externalize time (use prompts, pointers,
    neighbor timekeepers, etc.)
  • Dont surprise them--give ample warnings
  • Help control impulse buddy system may help slow
    down blurting/impulsivity

AccommodationsSpecific Strategies (9 of 10)
  • Help manage the environment 
  • For some, earplugs, headsets orwhite noise can
  • Use a divider, a cabinet or some boxes to create
    an isolated student office.
  • Keep the room a bit cooler for alertness
  • Aim the student towards a less distractingor
    disruptive area or view

AccommodationsSpecific Strategies (10 of 10)
  • Get the whole class involved. Hold short
    class meetings on behavior topics that will help
    those with AD/HD (and others). Do topics like
    behavior in transition orrespect or noise
    levels. Find out how students feel about it when
    others disrespect them, hit, name-call or butt in
    line. Do only one at a time.

Parent SuggestionsStudent Skill-Building (1 of 2)
  • Develop their understanding of personal strengths
    and weaknesses
  • Enroll your child in a martial arts program
  • Promote puzzles, model-building and card games
    which require focus and concentration
  • Videogames (without violence) can be helpful
  • Help students learn to handle criticism more

Parent Suggestions Student Skill-Building (2 of
  • Teach yoga, relaxation or meditation
  • Channel creative energy into the arts (music,
    drama, hands-on)
  • Acknowledge and comment on appropriate behavior,
    and offer rewards that foster cooperation and
    social interaction
  • Strongly consider neurofeedback training for
    their child.

Parent Suggestions Environmental Changes (1 of 2)
  • Give student a chance to customize his
  • Change teachers or classes
  • Provide consistent, immediate feedback
  • Provide structured daily schedules
  • Provide opportunities for movement
  • Establish consistent rules, routines, and

Parenting Suggestions Environmental Changes (2 of
  • Use background music it helps some to focus
  • Remove any environmentalrisks (e.g. lead,
  • Study with a good friend
  • Give prompts before key info
  • Enroll in alternative school
  • Provide positive role models

Classroom management
  • Seat the child in the back so he or she can
    stand and walk if needed.
  • Seat the child near a student role model and
    use egg timers for seatwork.
  • Use teams or study-buddies
  • Give sensory tools for using up energysuch as
    squeezable items or chin-up bar.
  • Focus on the big things avoid lettingthese
    students drive you crazy. Dont take their
    behaviors personally.

Building Student Assets (1 of 3)
  • Overall Approach
  • Put your efforts on internal empowerment rather
    than external control.
  • Help support students in discovering their inner
  • Remember we all have differences. Focus on what
    the student can do and work to build on strengths.

Building Student Assets (2 of 3)
  • Teach positive self-talk skills
  • Help the child understand human differences
  • Show them how they are different from and are
    similar to others
  • Support strong self-esteem
  • Use short-term contracts for behaviors
  • Teach problem-solving
  • Help students recognize non-verbal language and
    unwritten rules to enhance social and friendship

Building Student Assets (3 of 3)
  • Focus on the students interests and build
  • Teach study skills and how to use clocks,
    calendars and Post-its
  • How to organize and to highlight information
  • Teach your child to visualize and focus
  • Use effective communication skills, social
    skills, peer tutoring, cooperative learning, etc.

  • Nearly every accommodationyou are being asked to
    makeis simply high quality teaching.It does not
    give AD/HD studentsany advantage it simply
    levelsthe playing field.

Adults with AD/HD
  • The kids with AD/HD often have a parent with it,
  • In parent conferences, keep them focused on task.
    Theyll have a tendency to jump around.
  • Hold meetings early (if possible).Symptoms of
    AD/HD in adults are generally worse in the
  • Meet in a quiet place with few distractions, such
    as a conference room or classroom not in the
    teachers lounge or busy cafeteria.

Take Home Messages
  • Maintain the confidentiality of students
    identified with this condition!
  • AD/HD is not a disease nor is it a joke do not
    blame the person nor trivialize the condition.
  • Students with moderate to severe AD/HD are highly
    at risk for behavioral, emotional and academic
  • Those with AD/HD can and do succeed with proper
    diagnosis, intervention and support.

  • http//

Action Steps
  • What have you learned?
  • How might you think or behave differently?
  • Where and when might you begin?

Suggested Resource
  • A New View of AD/HDby Eric Jensen

Thank you!
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